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Wang Y, Yang J, Wen Y. The Peculiarity of Infection and Immunity Correlated with Guillain-Barré Syndrome in the HIV-Infected Population. J Clin Med 2023; 12:jcm12030907. [PMID: 36769555 PMCID: PMC9917483 DOI: 10.3390/jcm12030907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
Guillain-Barré syndrome (GBS) can occur at all stages of human immunodeficiency virus (HIV) infection. HIV, cytomegalovirus (CMV), and varicella zoster virus (VZV) are the main infectious agents in HIV-positive GBS cases. These cases include acute and chronic HIV infection, immune reconstitution inflammatory syndrome (IRIS) shortly after anti-retroviral therapy (ART), those with ART interruption, or those with cerebrospinal fluids (CSF) HIV escape. The mechanisms are involved in both humoral and cellular immunities. Demyelinating and axonal neuropathies are the main pathological mechanisms in GBS. Presentation and prognosis are identical to those in patients without HIV infection. Typical or atypical clinical manifestations, CSF analysis, electrophysiological and pathological examination, and antiganglioside antibody detection can help diagnose GBS and classify its various subtypes. Intravenous immunoglobulin and plasma exchange have been used to treat GBS in HIV-positive patients with a necessary ART, while ganciclovir or foscarnet sodium should be used to treat ongoing CMV- or VZV-associated GBS. Steroids may be beneficial for patients with IRIS-related GBS. We reviewed HIV-positive cases with GBS published since 2000 and summarized their features to highlight the necessity of HIV testing among patients with GBS. Moreover, the establishment of a multidisciplinary team will guarantee diagnostic and therapeutic advantages.
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Affiliation(s)
- Yanli Wang
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Jun Yang
- Neurology Department, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Ying Wen
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
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Vidal JE, Guedes BF, Gomes HR, Mendonça RH. Guillain-Barré syndrome spectrum as manifestation of HIV-related immune reconstitution inflammatory syndrome: case report and literature review. Braz J Infect Dis 2022; 26:102368. [PMID: 35605654 PMCID: PMC9387489 DOI: 10.1016/j.bjid.2022.102368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/30/2022] [Indexed: 11/29/2022] Open
Abstract
A 34-year-old man presented with a history of 21-days of gait unsteadiness and diplopia. Ten days before presentation, he developed limb weakness and in the last three days reduced consciousness. HIV infection was diagnosed three months ago (CD4+ = 160 cells/mm3; viral load HIV-1 = 144.000 copies/mL), and antiretroviral therapy was initiated. Impaired consciousness, ophthalmoplegia, limb weakness, ataxia, areflexia, and Babinsky´s sign were noted. At that moment, CD4+ count was 372 cells/mm 3 and viral load HIV-1 <50 copies/mL. The clinical, laboratory and neurophysiological findings suggest overlapping Guillain-Barre syndrome (GBS) and Bickerstaff brainstem encephalitis as manifestation of HIV-related immune reconstitution inflammatory syndrome (IRIS). Here, we review and discuss 7 cases (including the present report) of GBS spectrum as manifestation of HIV-related IRIS.
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Affiliation(s)
- José E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, SP, Brazil; Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Bruno F Guedes
- Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Hélio R Gomes
- Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Holanda Mendonça
- Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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3
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Ndondo AP, Eley B, Wilmshurst JM, Kakooza-Mwesige A, Giannoccaro MP, Willison HJ, Cruz PMR, Heckmann JM, Bateman K, Vincent A. Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective. Front Immunol 2022; 13:833548. [PMID: 35356001 PMCID: PMC8959857 DOI: 10.3389/fimmu.2022.833548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
The direct impact and sequelae of infections in children and adults result in significant morbidity and mortality especially when they involve the central (CNS) or peripheral nervous system (PNS). The historical understanding of the pathophysiology has been mostly focused on the direct impact of the various pathogens through neural tissue invasion. However, with the better understanding of neuroimmunology, there is a rapidly growing realization of the contribution of the innate and adaptive host immune responses in the pathogenesis of many CNS and PNS diseases. The balance between the protective and pathologic sequelae of immunity is fragile and can easily be tipped towards harm for the host. The matter of immune privilege and surveillance of the CNS/PNS compartments and the role of the blood-brain barrier (BBB) and blood nerve barrier (BNB) makes this even more complex. Our understanding of the pathogenesis of many post-infectious manifestations of various microbial agents remains elusive, especially in the diverse African setting. Our exploration and better understanding of the neuroimmunology of some of the infectious diseases that we encounter in the continent will go a long way into helping us to improve their management and therefore lessen the burden. Africa is diverse and uniquely poised because of the mix of the classic, well described, autoimmune disease entities and the specifically "tropical" conditions. This review explores the current understanding of some of the para- and post-infectious autoimmune manifestations of CNS and PNS diseases in the African context. We highlight the clinical presentations, diagnosis and treatment of these neurological disorders and underscore the knowledge gaps and perspectives for future research using disease models of conditions that we see in the continent, some of which are not uniquely African and, where relevant, include discussion of the proposed mechanisms underlying pathogen-induced autoimmunity. This review covers the following conditions as models and highlight those in which a relationship with COVID-19 infection has been reported: a) Acute Necrotizing Encephalopathy; b) Measles-associated encephalopathies; c) Human Immunodeficiency Virus (HIV) neuroimmune disorders, and particularly the difficulties associated with classical post-infectious autoimmune disorders such as the Guillain-Barré syndrome in the context of HIV and other infections. Finally, we describe NMDA-R encephalitis, which can be post-HSV encephalitis, summarise other antibody-mediated CNS diseases and describe myasthenia gravis as the classic antibody-mediated disease but with special features in Africa.
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Affiliation(s)
- Alvin Pumelele Ndondo
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Jo Madeleine Wilmshurst
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Department of Paediatric Neurology, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maria Pia Giannoccaro
- Laboratory of Neuromuscular Pathology and Neuroimmunology, Istituto di Ricovero e Cura a CarattereScientifico (IRCCS) Instiuto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Hugh J Willison
- Institute of Infection, Immunity and Inflammation (3I), University of Glasgow, Glasgow, United Kingdom
| | - Pedro M Rodríguez Cruz
- Centro Nacional de Analisis Genomico - Centre for Genomic Regulation (CNAG-CRG ), Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain.,Department of Neuromuscular Disease, University College London (UCL) Queen Square Institute of Neurology, London, United Kingdom.,Faculté de Médecine, de Pharmacie et d'Odontologie, Université Cheikh Anta Diop, Dakar, Senegal
| | - Jeannine M Heckmann
- Neurology Division, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.,The University of Cape Town (UCT) Neurosciences Institute, University of Cape Town, Cape Town, South Africa
| | - Kathleen Bateman
- Neurology Division, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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4
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Cheng AC, Lin TY, Wang NC. Immune Reconstitution Inflammatory Syndrome Induced by Mycobacterium avium Complex Infection Presenting as Chronic Inflammatory Demyelinating Polyneuropathy in a Young AIDS Patient. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010110. [PMID: 35056418 PMCID: PMC8779113 DOI: 10.3390/medicina58010110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 12/26/2022]
Abstract
Antiretroviral therapy (ART) can restore protective immune responses against opportunistic infections (OIs) and reduce mortality in patients with human immunodeficiency virus (HIV) infections. Some patients treated with ART may develop immune reconstitution inflammatory syndrome (IRIS). Mycobacterium avium complex (MAC)-related IRIS most commonly presents as lymphadenitis, soft-tissue abscesses, and deteriorating lung infiltrates. However, neurological presentations of IRIS induced by MAC have been rarely described. We report the case of a 31-year-old man with an HIV infection. He developed productive cough and chronic inflammatory demyelinating polyneuropathy (CIDP) three months after the initiation of ART. He experienced an excellent virological and immunological response. Sputum culture grew MAC. The patient was diagnosed with MAC-related IRIS presenting as CIDP, based on his history and laboratory, radiologic, and electrophysiological findings. Results: Neurological symptoms improved after plasmapheresis and intravenous immunoglobulin (IVIG) treatment. To our knowledge, this is the first reported case of CIDP due to MAC-related IRIS. Clinicians should consider MAC-related IRIS in the differential diagnosis of CIDP in patients with HIV infections following the initiation of ART.
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Affiliation(s)
- An-Che Cheng
- Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
| | - Te-Yu Lin
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
| | - Ning-Chi Wang
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
- Correspondence: ; Tel.: +886-2-287927257
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Abstract
PURPOSE OF REVIEW This article reviews the neurologic complications associated with human immunodeficiency virus (HIV) infection. RECENT FINDINGS Neurologic complications of HIV may be caused by direct virally mediated pathology, immune-mediated phenomena in response to viral infection, or opportunistic infections secondary to depletion of lymphocytes. These neurologic disorders may be influenced by the degree of immunosuppression (ie, CD4+ T-cell lymphocyte count) and stage of infection (early versus late), as well as use of antiretroviral therapy, and may manifest as a variety of central and peripheral neurologic syndromes, including the more commonly encountered HIV-associated cognitive disorders and length-dependent sensorimotor polyneuropathy, respectively. Immune dysregulation underlies the majority of these neurologic phenomena, as well as other HIV-associated conditions including immune reconstitution inflammatory syndrome (IRIS), CD8 lymphocytosis, and potentially the development of compartmentalized infection within the CSF, also referred to as CSF escape. SUMMARY This article reviews a spectrum of clinical syndromes and related neuropathologic states associated with HIV infection.
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A Rare Case of HIV-Induced Inflammatory Demyelinating Polyneuropathy. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2019; 7:5-8. [PMID: 30899779 PMCID: PMC6424340 DOI: 10.12691/ajmcr-7-1-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Acute inflammatory demyelinating polyneuropathy (AIDP) is an uncommon form of neuropathy in HIV-infected patients that can cause pain, sensory disturbance, and motor weakness. Case presentation A 23-year-old African American male with past medical history of Guillain-Barre Syndrome (GBS), Lyme disease, and sexually transmitted infections including syphilis and chlamydia presented with acute back pain radiating to bilateral lower extremities with worsening right foot weakness for four days. Cerebrospinal fluid (CSF) studies including meningoencephalitis panel were negative as well as blood tests for Lyme disease and HIV antibody testing. Patient was initially treated with penicillin for positive treponemal serology but without improvement in lower extremity weakness. Electromyogram showed evidence of early demyelinating motor polyneuropathy. Four days after presentation, repeat HIV antibody testing returned positive. Recurrent AIDP in this case was suspected to be secondary to acute HIV infection, and highly active antiretroviral therapy (HAART) was administered along with intravenous immunoglobulin (IVIG). Muscle strength improved with therapy and patient was expected to have continued improvement with intensive rehabilitation after discharge. Conclusion Acute inflammatory demyelinating polyneuropathy (AIDP) tends to present early in course of HIV infection. Therefore, HIV testing should be obtained in individuals presenting with new neurological deficits. Our patient received HAART therapy, in addition to the traditional modalities to manage AIDP, which led to a substantial recovery of his sensorimotor function.
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7
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Mathukumalli NL, Ali N, Kanikannan MA, Yareeda S. Worsening Guillain-Barré syndrome: harbinger of IRIS in HIV? BMJ Case Rep 2017; 2017:bcr-2017-221874. [PMID: 29030378 DOI: 10.1136/bcr-2017-221874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report an HIV patient aged 38 years with acute inflammatory demyelinating polyradiculoneuropathy subtype of Guillain-Barré syndrome (GBS) as the only manifestation of seroconversion and worsening of GBS being the harbinger of immune reconstitution inflammatory syndrome (IRIS). To date, only 5 cases of GBS during IRIS are reported. They manifested either during the third week or later after starting highly active antiretroviral therapy (HAART). Our patient witnessed worsening weakness by fifth day after starting HAART, even before the occurrence of Pneumocystis jirovecii pneumonia, cautioning one of the impending serious complications of IRIS and helped us initiate steroids at an early date.
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Affiliation(s)
| | - Niloufer Ali
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Meena A Kanikannan
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sireesha Yareeda
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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8
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Rosca EC, Rosca O, Simu M. Intravenous immunoglobulin treatment in a HIV-1 positive patient with Guillain-Barré syndrome. Int Immunopharmacol 2015; 29:964-965. [PMID: 26428850 DOI: 10.1016/j.intimp.2015.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 09/22/2015] [Accepted: 09/24/2015] [Indexed: 11/25/2022]
Abstract
We report the case of an HIV-1 positive patient with primary demyelinating neuropathy (Guillain-Barré syndrome); after intravenous immunoglobulin treatment (IVIG), he presented with an increase in CD4 and CD8 cell counts and a decrease in plasma viral load. Currently, there is little reported research regarding IVIG treatment in adults with HIV-1. The present report brings further evidence regarding the possible benefit of IVIG in HIV-1 infected patients, providing a novel perspective on treatment.
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Affiliation(s)
- Elena Cecilia Rosca
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Department of Neurology, Romania; Clinical Emergency County Hospital Timisoara, Department of Neurology, Romania.
| | - Ovidiu Rosca
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Department of Infectious Diseases, Romania
| | - Mihaela Simu
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Department of Neurology, Romania; Clinical Emergency County Hospital Timisoara, Department of Neurology, Romania
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9
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Manzardo C, Guardo AC, Letang E, Plana M, Gatell JM, Miro JM. Opportunistic infections and immune reconstitution inflammatory syndrome in HIV-1-infected adults in the combined antiretroviral therapy era: a comprehensive review. Expert Rev Anti Infect Ther 2015; 13:751-67. [PMID: 25860288 DOI: 10.1586/14787210.2015.1029917] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the availability of effective combined antiretroviral treatment, many patients still present with advanced HIV infection, often accompanied by an AIDS-defining disease. A subgroup of patients starting antiretroviral treatment under these clinical conditions may experience paradoxical worsening of their disease as a result of an exaggerated immune response towards an active (but also subclinical) infectious agent, despite an appropriate virological and immunological response to the treatment. This clinical condition, known as immune reconstitution inflammatory syndrome, may cause significant morbidity and even mortality if it is not promptly recognized and treated. This review updates current knowledge about the incidence, diagnostic criteria, risk factors, clinical manifestations, and management of opportunistic infections and immune reconstitution inflammatory syndrome in the combined antiretroviral treatment era.
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Affiliation(s)
- Christian Manzardo
- Infectious Diseases Service and HIV Research Unit, Hospital Clinic - IDIBAPS, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
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10
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Afzal A, Benjamin M, Gummelt KL, Afzal S, Shamim S, Tribble M. Ascending paralysis associated with HIV infection. Proc AMIA Symp 2015; 28:25-8. [PMID: 25552790 PMCID: PMC4264702 DOI: 10.1080/08998280.2015.11929176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We present two patients with a high viral load of HIV-1 who developed symptoms of ascending paralysis leading to respiratory failure and autonomic instability. One patient had symptom improvement with highly active antiretroviral therapy (HAART) and a subsequent decrease in viral load. The other patient improved with intravenous immunoglobulin therapy and did not show much improvement on HAART alone. There are several proposed mechanisms for peripheral neuropathies seen in HIV-infected patients, including a direct action of HIV on the nerve by neurotropic strains or formation of autoantibodies against nerve elements. The comparison of the response to different therapies in these two cases highlights the importance of understanding different pathophysiologies, as the treatment modality may differ.
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Affiliation(s)
- Aasim Afzal
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Mina Benjamin
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Kyle L Gummelt
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Sadaf Afzal
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Sadat Shamim
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
| | - Marc Tribble
- Department of Internal Medicine (Afzal, Benjamin, Gummelt), the Division of Neurology (Shamim), and the Division of Infectious Diseases (Tribble), Baylor University Medical Center at Dallas
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11
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Abstract
Peripheral nerve disorders are associated with all stages of HIV infection. Distal sensory polyneuropathy is characterised by often-disabling pain that is difficult to treat. It is prevalent in both high-income and low-income settings. In low-income settings, use of potentially neurotoxic antiretrovirals, which are inexpensive and widely available, contributes substantially to incidence. Research has focused on identification of factors that predict risk of distal sensory polyneuropathy and elucidation of the multifactorial mechanisms behind pathogenesis. Sensorimotor polyneuropathies and polyradiculopathies are less frequent than distal sensory polyneuropathy, but still occur in low-income settings and have potentially devastating consequences. However, many of these diseases can be treated successfully with a combination of antiretroviral and immune-modulating therapies. To distinguish between peripheral nerve disorders that have diverse, overlapping, and frequently atypical presentations can be challenging; a framework based on a clinicoanatomical approach might assist in the diagnosis and management of such disorders.
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12
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Abstract
Peripheral neuropathies are the most common neurological manifestations occurring in HIV-infected individuals. Distal symmetrical sensory neuropathy is the most common form encountered today and is one of the few that are specific to HIV infection or its treatment. The wide variety of other neuropathies is akin to the neuropathies seen in the general population and should be managed accordingly. In the pre-ART era, neuropathies were categorized according to the CD4 count and HIV viral load. In the early stages of HIV infection when CD4 count is high, the inflammatory demyelinating neuropathies predominate and in the late stages with the decline of CD4 count opportunistic infection-related neuropathies prevail. That scenario has changed with the present almost universal use of ART (antiretroviral therapy). Hence, HIV-associated peripheral neuropathies are better classified according to their clinical presentations: distal symmetrical polyneuropathy, acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), mononeuropathies, mononeuropathies multiplex and cranial neuropathies, autonomic neuropathy, lumbosacral polyradiculomyelopathy, and amyotrophic lateral sclerosis (ALS)-like motor neuropathy. Treated with ART, HIV-infected individuals are living longer and are at a higher risk of metabolic and age-related complications; moreover they are also prone to the potentially neurotoxic effects of ART. There are no epidemiological data regarding the incidence and prevalence of the peripheral neuropathies. In the pre-ART era, most data were from case reports, series of patients, and pooled autopsy data. At that time the histopathological evidence of neuropathies in autopsy series was almost 100%. In large prospective cohorts presently being evaluated, it has been found that 57% of HIV-infected individuals have distal symmetrical sensory neuropathy and 38% have neuropathic pain. It is now clear that distal symmetrical sensory neuropathy is caused predominantly by the ART's neurotoxic effect but may also be caused by the HIV itself. With a sizeable morbidity, the neuropathic pain caused by distal symmetrical sensory neuropathy is very difficult to manage; it is often necessary to change the ART regimen before deciding upon the putative role of HIV infection itself. If the change does not improve the pain, there are few options available; the most common drugs used for neuropathic pain are usually not effective. One is left with cannabis, which cannot be recommended as routine therapy, recombinant human nerve growth factor, which is unavailable, and topical capsaicin with its side-effects. Much has been done to and learned from HIV infection in humans; HIV-infected individuals, treated with ART, are now dying mostly from cardiovascular disease and non-AIDS-related cancers. It hence behooves us to find new approaches to mitigate the residual neurological morbidity that still impacts the quality of life of that population.
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Affiliation(s)
- Alberto Alain Gabbai
- Department of Neurology, UNIFESP-Escola Paulista de Medicina, São Paulo, Brazil.
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13
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Guillain-Barré Syndrome with Fatal Outcome during HIV-1-Seroconversion: A Case Report. Case Rep Infect Dis 2011; 2011:972096. [PMID: 22567484 PMCID: PMC3336224 DOI: 10.1155/2011/972096] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 06/21/2011] [Indexed: 11/22/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute or subacute peripheral polyneuropathy characterized by symmetrical muscle weakness. Its occurrence has been reported during acute HIV seroconversion since 1985. Among HIV-infected subjects, GBS has generally a favourable outcome. We report a case of GBS with fatal outcome during HIV seroconversion.
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14
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Capers KN, Turnacioglu S, Leshner RT, Crawford JR. Antiretroviral therapy-associated acute motor and sensory axonal neuropathy. Case Rep Neurol 2011; 3:1-6. [PMID: 21327178 PMCID: PMC3037986 DOI: 10.1159/000322573] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Guillain-Barré syndrome (GBS) has been reported in HIV-infected patients in association with the immune reconstitution syndrome whose symptoms can be mimicked by highly active antiretroviral therapy (HAART)-mediated mitochondrial toxicity. We report a case of a 17-year-old, HIV-infected patient on HAART with a normal CD4 count and undetectable viral load, presenting with acute lower extremity weakness associated with lactatemia. Electromyography/nerve conduction studies revealed absent sensory potentials and decreased compound muscle action potentials, consistent with a diagnosis of acute motor and sensory axonal neuropathy. Lactatemia resolved following cessation of HAART; however, neurological deficits minimally improved over several months in spite of immune modulatory therapy. This case highlights the potential association between HAART, mitochondrial toxicity and acute axonal neuropathies in HIV-infected patients, distinct from the immune reconstitution syndrome.
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Affiliation(s)
- Kimberly N Capers
- Department of Neurology, Children's National Medical Center, The George Washington University School of Medicine, Washington, D.C
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15
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Steiner I, Rosenberg G, Wirguin I. Transient immunosuppression: a bridge between infection and the atypical autoimmunity of Guillain-Barré syndrome? Clin Exp Immunol 2010; 162:32-40. [PMID: 20735441 DOI: 10.1111/j.1365-2249.2010.04223.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute, usually monophasic, disorder of the peripheral nervous system that is assumed to be of immune-mediated pathogenesis. However, several clinical features and experimental findings of GBS are uncharacteristic for an immune-mediated disorder and set this condition apart from other disorders with a putative immune-mediated pathogenesis. These features include, among others, the monophasic nature of GBS, the lack of response to immunosuppressive (unlike immunomodulatory) therapy, the absence of a typical association with immunogenetic background and the inability to establish a valid and relevant animal model. We suggest a comprehensive hypothesis for the pathogenesis of GBS that is based on the assumption that the condition is due to a transient (or occasionally chronic) immune deficiency, as in most cases GBS follows an infection with pathogens known to induce immunosuppression. Such infections may be followed by breakdown of immune tolerance and induction of an immune attack on peripheral nerves. Mounting of the immune-mediated assault might be triggered either by the same infective pathogen or by secondary infection. Clearance of the infection and resumption of a normal immune response and tolerance eventually terminate the immune-mediated damage to the peripheral nerves and enable recovery. This hypothesis assumes that the entire sequence of events that culminates in GBS is due to transient exogenous factors and excludes a significant role for inherent host susceptibility, which explains the monophasic nature of the disorder.
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Affiliation(s)
- I Steiner
- Department of Neurology, Rabin Medical Center, Petah Tiqva, D-Pharm Ltd, Kiryat Weizmann Science Park, Rehovot, Israel.
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16
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Dhasmana DJ, Dheda K, Ravn P, Wilkinson RJ, Meintjes G. Immune reconstitution inflammatory syndrome in HIV-infected patients receiving antiretroviral therapy : pathogenesis, clinical manifestations and management. Drugs 2008; 68:191-208. [PMID: 18197725 DOI: 10.2165/00003495-200868020-00004] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The use of antiretroviral therapy (ART) to treat HIV infection, by restoring CD4+ cell count and immune function, is associated with significant reductions in morbidity and mortality. Soon after ART initiation, there is a rapid phase of restoration of pathogen-specific immunity. In certain patients, this results in inflammatory responses that may result in clinical deterioration known as 'the immune reconstitution inflammatory syndrome' (IRIS). IRIS may be targeted at viable infective antigens, dead or dying infective antigens, host antigens, tumour antigens and other antigens, giving rise to a heterogeneous range of clinical manifestations. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. In most patients, ART should be continued and treatment for the associated condition optimized, and there is anecdotal evidence for the use of corticosteroids in patients who are severely affected. In this review, we discuss research relating to pathogenesis, the range of clinical manifestations, treatment options and prevention issues.
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Affiliation(s)
- Devesh J Dhasmana
- Department of Respiratory Medicine, Harefield Hospital, Middlesex, UK
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17
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de Castro G, Bastos PG, Martinez R, de Castro Figueiredo JF. Episodes of Guillain-Barré syndrome associated with the acute phase of HIV-1 infection and with recurrence of viremia. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 64:606-8. [PMID: 17119803 DOI: 10.1590/s0004-282x2006000400016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Accepted: 05/06/2006] [Indexed: 11/22/2022]
Abstract
We report a severe case of Guillain-Barré syndrome (GBS) characterized by flaccid areflexive tetraplegia and signs of autonomic instability related to acute HIV-1 infection, and the occurrence of relapse episodes coinciding with the detection of HIV-1 RNA in blood during the phase of irregular treatment with antiretroviral agents. The patient has been asymptomatic for 3 years and has an HIV-1 load below the limit of detection. The recurrence of GBS in this case may be related to alterations of the immunologic response caused by disequilibrium in the host-HIV relationship due to the increase in HIV-1 viremia.
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Affiliation(s)
- Gleusa de Castro
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
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18
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Houff SA, Major EO. Neuropharmacology of HIV/AIDS. HANDBOOK OF CLINICAL NEUROLOGY 2007; 85:319-364. [PMID: 18808990 DOI: 10.1016/s0072-9752(07)85019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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19
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Hickman SJ, Sanyal A, Manji H, Groves MJ, Giovannoni G. "Double whammy" neuropathy: a 37-year-old woman with burning and weakness in both legs. Lancet Neurol 2006; 5:632-6. [PMID: 16781993 DOI: 10.1016/s1474-4422(06)70498-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Simon J Hickman
- Department of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK.
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Ferrari S, Vento S, Monaco S, Cavallaro T, Cainelli F, Rizzuto N, Temesgen Z. Human immunodeficiency virus-associated peripheral neuropathies. Mayo Clin Proc 2006; 81:213-9. [PMID: 16471077 DOI: 10.4065/81.2.213] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Peripheral neuropathy has emerged as the most common neurologic complication of human immunodeficiency virus (HIV) infection. It will continue to play an Important role in HIV Infection given the fact that HIV-infected Individuals are living longer, are at risk of long-term metabolic complications, and face an Increasing exposure to potentially neurotoxic antiretroviral drugs. We review the various types of peripheral neuropathy that have been associated with HIV infection, including distal symmetrical polyneuropathy, toxic neuropathy from antiretroviral drugs, diffuse infiltrative lymphocytosis syndrome, inflammatory demyelinating polyneuropathies, multifocal mononeuropathies, and progressive polyradiculopathy.
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Affiliation(s)
- Sergio Ferrari
- Department of Neurological and Visual Sciences, Section of Neurology, University of Verona, Verona, Italy
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21
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Stoll M, Schmidt RE. Immune restoration inflammatory syndromes: Apparently paradoxical clinical events after the initiation of HAART. Curr HIV/AIDS Rep 2004; 1:122-7. [PMID: 16091232 DOI: 10.1007/s11904-004-0018-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immune reconstitution occurs after initiation of highly active antiretroviral therapy in immunodeficient HIV-positive individuals. Unexpected deterioration of inflammatory disease and atypical clinical features resembling symptoms of autoimmune disease may arise. These atypical inflammatory disorders, synonymously summarized as immune reconstitution syndrome, immune restoration disease, and immune restoration inflammatory syndrome (IRIS), are caused by augmentation of inflammation during immune reconstitution in an immunocompromised host. These disorders have to be distinguished from intercurrent infection and rheumatic disease, respectively. Treatment of IRIS consists of elements for both potential differential diagnoses (ie, anti-inflammatory and immunosuppressive drugs, such as in autoimmune disorders and antimicrobial chemotherapy, to decrease the burden of pathogen, such as in infectious disease). Therefore, awareness for IRIS is of increasing importance from a clinical point of view. However, diagnostic criteria and standards of treatment are still preliminary.
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Affiliation(s)
- Matthias Stoll
- Department Clinical Immunology, Medical School Hannover, Carl Neuberg Street 1, D-30625 Hannover, Germany.
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22
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Abstract
Suppression of HIV replication by highly active antiretroviral therapy (HAART) often restores protective pathogen-specific immune responses, but in some patients the restored immune response is immunopathological and causes disease [immune restoration disease (IRD)]. Infections by mycobacteria, cryptococci, herpesviruses, hepatitis B and C virus, and JC virus are the most common pathogens associated with infectious IRD. Sarcoid IRD and autoimmune IRD occur less commonly. Infectious IRD presenting during the first 3 months of therapy appears to reflect an immune response against an active (often quiescent) infection by opportunistic pathogens whereas late IRD may result from an immune response against the antigens of non-viable pathogens. Data on the immunopathogenesis of IRD is limited but it suggests that immunopathogenic mechanisms are determined by the pathogen. For example, mycobacterial IRD is associated with delayed-type hypersensitivity responses to mycobacterial antigens whereas there is evidence of a CD8 T-cell response in herpesvirus IRD. Furthermore, the association of different cytokine gene polymorphisms with mycobacterial or herpesvirus IRD provides evidence of different pathogenic mechanisms as well as indicating a genetic susceptibility to IRD. Differentiation of IRD from an opportunistic infection is important because IRD indicates a successful, albeit undesirable, effect of HAART. It is also important to differentiate IRD from drug toxicity to avoid unnecessary cessation of HAART. The management of IRD often requires the use of anti-microbial and/or anti-inflammatory therapy. Investigation of strategies to prevent IRD is a priority, particularly in developing countries, and requires the development of risk assessment methods and diagnostic criteria.
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Affiliation(s)
- Martyn A French
- Department of Clinical Immunology and Biochemical Genetics, Royal Perth Hospital and School of Surgery and Pathology, University of Western Australia, Perth, Australia.
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Abstract
Increase of prevalence of certain immunodeficiencies is caused by more frequent use of immunosuppresive treatment, by advances in supportive care of immunodeficient individuals and by the pandemic spread of HIV-infection respectively. Highly active antiretroviral treatment (HAART) is able to reconstitute the impaired immunity in the HIV-infected individual and therefore to reduce morbidity and mortality. On the other hand paradoxical exacerbation of inflammatory or opportunistic diseases may develop during immunoreconstitution. By their distinct pathophysiological, clinical and therapeutic particularities these disease have been summarized as Immune Restoration Inflammatory Syndromes (IRIS). This review summarizes the variety of immunoreconstitution disorders and describes possible diagnostic pitfalls. Potential therapeutic options and an algorithm for the classification of the syndrome are proposed.
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Affiliation(s)
- M Stoll
- Abteilung Klinische Immunologie, Medizinische Hochschule Hannover.
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Robertson P, Scadden DT. Immune reconstitution in HIV infection and its relationship to cancer. Hematol Oncol Clin North Am 2003; 17:703-16, vi. [PMID: 12852652 DOI: 10.1016/s0889-8588(03)00047-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
HIV infection results in formidable immune dysfunction, widely affecting the immune system, but typified by T lymphopenia. This dysfunction includes a perturbed immune response to several persistent viruses that have a propensity to cause tumors. Effective control of HIV replication by highly active antiretroviral therapy (HAART) results in regeneration of the damaged immune system, and recent advances have allowed this immune reconstitution to be better defined. This article describes the immunodeficiency caused by HIV and the response of the immune system to HAART, with specific reference to the immune response to cancers associated with HIV infection.
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Affiliation(s)
- Paul Robertson
- AIDS Research Center, Massachusetts General Hospital, Harvard Medical School 149, 13th Street, Room 5212, Boston, MA 02109, USA
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Stoll M, Schmidt RE. Immune Restoration Inflammatory Syndromes: The Dark Side of Successful Antiretroviral Treatment. Curr Infect Dis Rep 2003; 5:266-276. [PMID: 12760825 DOI: 10.1007/s11908-003-0083-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The prevalence of cellular immunodeficiency has increased due to rising use of immunosuppressive therapies and the pandemic spread of HIV infection. More recently, the introduction of highly active antiretroviral therapy (HAART) in HIV has led to significant immune reconstitution, even in patients with previously long-lasting secondary immunodeficiency. HAART reduces morbidity and mortality in HIV infection and also changes the clinical course of prevalent subclinical opportunistic infections or autoimmune diseases. Atypical inflammatory disorders develop after initiation of HAART and have been summarized as "immune reconstitution syndrome," "immune restoration disease," and "immune restoration inflammatory syndrome." However, diagnostic criteria and standards of therapy are yet to be defined. The awareness for these diseases is of increasing importance from a clinical point of view. This review summarizes the variety of immunoreconstitution disorders and describes possible diagnostic pitfalls. We also propose possible therapeutic options.
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Affiliation(s)
- Matthias Stoll
- Department Clinical Immunology, Medical School Hannover, Carl Neuberg Str. 1, D-30625 Hannover, Germany.
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Piliero PJ, Fish DG, Preston S, Cunningham D, Kinchelow T, Salgo M, Qian J, Drusano GL. Guillain-Barré syndrome associated with immune reconstitution. Clin Infect Dis 2003; 36:e111-4. [PMID: 12715328 DOI: 10.1086/368311] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2002] [Accepted: 12/25/2002] [Indexed: 11/03/2022] Open
Abstract
We report a case of acute Guillain-Barré syndrome (GBS) associated with a prompt and vigorous immune reconstitution and decrease in the virus load noted during treatment with a potent regimen of highly active antiretroviral therapy. We hypothesize that GBS may have been due to an aberrant immune response or an adverse drug reaction in association with preexisting peripheral neurologic disease.
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